Columbia Healthcare Center
Inspection Findings
F-Tag F0658
F 0658
Ensure services provided by the nursing facility meet professional standards of quality.
Level of Harm - Minimal harm or potential for actual harm
Based on interview, and record review, the facility failed to follow Physicians Orders. A resident with a pressure ulcer did not receive antibiotics and treatment as ordered for 1 of 4 residents reviewed for quality of care. (Resident C)Finding includes:On 11/12/25 at 11:40 A.M., Resident C's clinical record was reviewed. Diagnoses included, but were not limited to, type 2 diabetes mellitus and gout.The most recent Significant Change Minimum Data Set (MDS) Assessment, dated 9/29/25, indicated Resident C had moderate cognitive impairment, 1 unstageable pressure ulcer, and was not on a turning and repositioning program. Resident C required substantial to maximal assistance of staff (staff performs more than half the effort) for transfers and toileting.Care plans included, but were not limited to, the following:Impaired mobility related to right foot osteomyelitis with an intervention to turn and reposition Resident C every 2 hours, dated 10/21/25.The resident had a right heel infection with an intervention to administer antibiotics as ordered by the physician, dated 10/16/25.Physicians' Orders included, but were not limited to, the following:Clindamycin (antibiotic) 300 milligrams (mg) oral every 6 hours for wounds started on 8/27/25 and discontinued on 9/1/25.Resident C's medication administration record (MAR) lacked documentation that the dose on 9/1/25 at 4:00 A.M. was administered.Right lateral heel: cleanse with wound cleanser, pat dry, apply skin prep to peri-wound, apply medi-honey to wound bed, then calcium alginate, cover with foam dressing. Change every day and as needed if soiled or dislodged. Started on 9/26/25 and discontinued on 10/1/25.Resident C's clinical record and treatment administration record (TAR) lacked documentation that
the wound treatment was completed on 9/26/25 from 6:00 A.M. to 6:00 P.M.Cephalexin (antibiotic) 500 mg oral every 8 hours started on 10/6/25 and discontinued on 10/13/25.Resident C's MAR lacked documentation that cephalexin was administered on 10/10/25 at 8:00 P.M. and on 10/11/25 at 12:00 P.M.Right lateral heel: cleanse with wound cleanser, pat dry, apply gauze with wound cleanser to wound bed, cover with an abdominal pad, and wrap with kerlix twice a day, started on 10/15/25.Resident C's clinical record and TAR indicate the treatment was not completed on 10/16/25 and 10/18/25 from 6:00 P.M. through 6:00 A.M. due to the resident sleeping, 10/21/25 from 6:00 P.M. through 6:00 A.M. due to the resident's condition, and 10/21/25 due to the resident was unavailable.During an interview on 11/13/25 at 11:28 A.M., Certified Nurse Aide (CNA) 3 indicated Resident C was not a resident who needed to be turned and repositioned every 2 hours. At that time, CNA 3 verified on the CNA assignment form that Resident C was not listed as a resident who needed to be turned and repositioned every 2 hours.During an
interview on 11/13/25 at 1:25 P.M., the DON indicated Resident C was supposed to be turned and repositioned every 2 hours. The treatments should have been completed as ordered, and the MAR and TAR should not have been left blank. She further indicated that if Resident C was asleep, staff should have attempted to wake the resident.On 11/13/25 at 1:19 P.M., the Assistant Administrator indicated the facility did not have a policy related to following Physician's Orders, but it would be their policy to follow orders.This citation was related to intake 2657654.3.1-35(g)(1)
Residents Affected - Few
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99) Previous Versions Obsolete
Facility ID:
If continuation sheet
Event ID:
COLUMBIA HEALTHCARE CENTER in EVANSVILLE, IN inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in EVANSVILLE, IN, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from COLUMBIA HEALTHCARE CENTER or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.